Somatic Mentoring & Coaching Application Form

SECTION 1 - BASIC DETAILS

First name

Last name

Pronouns

Phone / WhatsApp

Country & Time Zone

Preferred Contact Method

Other

If you feel comfortable and have the capacity right now, you’re welcome to share more about your current challenges or what you’re hoping to explore with Francesca.

This part is completely optional. You can submit the form without filling it in.

SECTION 2 - ACCESS, NEEDS & NEURODIVERGENCE

Neurodivergence (ADHD, Autism, Dyslexia, unsure, etc.)

Diagnosis Status

How does your neurodivergence show up day to day?

Accessibility or communication needs

SECTION 3 - WHY YOU’RE HERE

What made you reach out now?

Main challenges you're experiencing

What would you love to shift in the next 3‒6 months?

Readiness (1‒10)

SECTION 4 - SOMATIC WORK & SAFETY

Any previous therapy, coaching, somatic work?

What was helpful or unhelpful in past support?

Current support (therapist, GP, etc.)

Mental-health history you'd like me to be aware of

Any current safety concerns (self-harm thoughts, etc.)

Physical health considerations for somatic work

SECTION 5 - PRACTICAL THINGS

Preferred session format

Best days/times for sessions

Type of support you're interested in

Anything that might affect attending regularly

SECTION 6 - HOW YOU LIKE TO BE SUPPORTED

Support style preference

How you best process information

Anything you don't want in sessions

SECTION 7 - CONSENT & NEXT STEPS

How did you find me?

Anything you'd like me to know before we speak

Consent (type YES to confirm you understand coaching is not therapy)

Signature / Typed Name

Date

Month

Day

Year